Doing the right thing at the right time: Assessing responses to patient deterioration in electronic simulation scenarios using course-of-action analysis

International studies indicate that the recognition and management of deteriorating patients in hospitals are poor and that patient assessment is often inadequate. Face-to-face simulation programs have been shown to have an impact on educational and clinical outcomes; however, little is known about performance in contemporary healthcare e-simulation approaches. Using data from an open-access Web-based patient deterioration program (FIRSTACTWeb), the performance of 367 Australian nursing students in identification of treatment priorities and clinical actions was analyzed using a military model of Course of Action Simulation Analysis. Participants' performance in the whole program demonstrated a significant improvement in knowledge and skills (P ≤ .001) with high levels of participant satisfaction. Course of Action Simulation Analysis modeling identified three key participant groupings within which only 18% took the "best course of action" (the right actions and timing), with most (70%) completing the right actions but in the wrong order. The remaining 12% produced incomplete assessments and actions in an incorrect sequence. Contemporary approaches such as e-simulation do enhance educational outcomes. Measurement of performance when combined with Course of Action Simulation Analysis becomes a useful tool in the description of outcomes, an understanding of decision making, and the prediction of future events.

Effects of emergence time and early social rearing environment on behaviour of Atlantic salmon: consequences for juvenile fitness and smolt migration

Consistent individual differences in behaviour have been well documented in a variety of animal taxa, but surprisingly little is known about the fitness and life-history consequences of such individual variation. In wild salmonids, the timing of fry emergence from gravel spawning nests has been suggested to be coupled with individual behavioural traits. Here, we further investigate the link between timing of spawning nest emergence and behaviour of Atlantic salmon (Salmo salar), test effects of social rearing environment on behavioural traits in fish with different emergence times, and assess whether behavioural traits measured in the laboratory predict growth, survival, and migration status in the wild. Atlantic salmon fry were sorted with respect to emergence time from artificial spawning nest into three groups: early, intermediate, and late. These emergence groups were hatchery-reared separately or in co-culture for four months to test effects of social rearing environment on behavioural traits. Twenty fish from each of the six treatment groups were then subjected to three individual-based behavioural tests: basal locomotor activity, boldness, and escape response. Following behavioural characterization, the fish were released into a near-natural experimental stream. Results showed differences in escape behaviour between emergence groups in a net restraining test, but the social rearing environment did not affect individual behavioural expression. Emergence time and social environment had no significant effects on survival, growth, and migration status in the stream, although migration propensity was 1.4 to 1.9 times higher for early emerging individuals that were reared separately. In addition, despite individuals showing considerable variation in behaviour across treatment groups, this was not translated into differences in growth, survival, and migration status. Hence, our study adds to the view that fitness (i.e., growth and survival) and life-history predictions from laboratory measures of behaviour should be made with caution and ideally tested in nature.

Colorectal multidisciplinary meetings: how do they affect the timeliness of treatment?

BACKGROUND: The aim of this study is to determine whether multidisciplinary team (MDT) meetings alter the length of time to treatment (LOTT) for patients with colorectal cancer. METHODS: We conducted a retrospective audit of all patients with colorectal cancer from the Geelong Hospital (TGH) mandatory colorectal database from 1 January 2006 to 3 February 2011. To be included, patients had to have had elective surgical intervention for primary colorectal adenocarcinoma. A comparison of historical controls was conducted between patients discussed in MDT meetings and those managed prior to the introduction of MDT meetings (3 October 2006) to determine the LOTT in days from definitive diagnosis (colonoscopy) to definitive management (surgery, radiotherapy or chemotherapy). RESULTS: In total, the median LOTT for the historical control and MDT era patient populations were 19.5 and 20 days, respectively. Within the MDT era, we noticed significantly longer times to treatment for patients with rectal cancer who were seen in an MDT meeting prior to definitive management than patients who did not have an intervening MDT meeting (P < 0.001). With a difference of 7.5 days, the clinical significance of these findings remains contentious. However, it is worthwhile recognizing this trend in patients who are exhibiting symptoms due to near obstruction or significant bleeding. The LOTT for colon cancer patients remained unchanged. CONCLUSION: The introduction of MDT meetings to TGH has prolonged the LOTT for patients with rectal cancer. These findings pave the way for further revision of the efficiency of MDT meeting at TGH.

N-Acetyl Cysteine (NAC) in the treatment of obsessive-compulsive disorder: a 16-week, double-blind, randomised, placebo-controlled study

BACKGROUND: Obsessive-compulsive disorder (OCD) is a disabling mental illness for which pharmacological and psychosocial interventions are all too often inadequate. Recent preclinical and clinical studies have implicated dysfunction of glutamatergic neurotransmission in the pathophysiology of OCD. The amino acid-based nutraceutical N-acetyl cysteine (NAC) is a safe and readily available agent that has been found to modify the synaptic release of glutamate in subcortical brain regions via modulation of the cysteine-glutamate antiporter. OBJECTIVE: The aim of this study was to assess the efficacy and safety of NAC in treating OCD. METHODS: A 16-week, double-blind, placebo-controlled, randomised trial using 3 g/day of NAC (1.5 g twice daily) in 44 participants (aged 18-70 years) with Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5)-diagnosed OCD, during 2013-2015. The primary outcome measure was the Yale-Brown Obsessive Compulsive Scale (YBOCS), conducted every 4 weeks. RESULTS: Analysis of the full sample (intention-to-treat) with repeated measures mixed linear modelling revealed a nonsignificant time &times; treatment interaction for the YBOCS scale total score (p = 0.39). A per-protocol analysis removing protocol violators also failed to show a significant time &times; treatment interaction for YBOCS total score (p = 0.15). However, a significant time &times; treatment interaction was observed for the YBOCS 'Compulsions' subscale in favour of NAC (p = 0.013), with a significant reduction observed at week 12 (dissipating at week 16). At 16 weeks, only four (20 %) participants were considered 'responders' (YBOCS ≥35 % reduction at endpoint) versus four (27 %) in the placebo group. The NAC was well-tolerated, aside from more cases of heartburn occurring compared with placebo (p = 0.045). CONCLUSION: Further research involving NAC for OCD may require larger samples to detect moderate or small effect sizes, involve dosage or formulation differences, use in concert with exposure therapy, or an additional post-study observational period to mitigate study withdrawal. TRIAL REGISTRATION: ACTRN12613000310763.

Understanding toxicities and complications of cancer treatment: a data mining approach

Cancer remains a major challenge in modern medicine. Increasing prevalence of cancer, particularly in developing countries, demands better understanding of the effectiveness and adverse consequences of different cancer treatment regimes in real patient population. Current understanding of cancer treatment toxicities is often derived from either “clean” patient cohorts or coarse population statistics. It is difficult to get up-to-date and local assessment of treatment toxicities for specific cancer centres. In this paper, we applied an Apriori-based method for discovering toxicity progression patterns in the form of temporal association rules. Our experiments show the effectiveness of the proposed method in discovering major toxicity patterns in comparison with the pairwise association analysis. Our method is applicable for most cancer centres with even rudimentary electronic medical records and has the potential to provide real-time surveillance and quality assurance in cancer care.

Affective instability and the course of bipolar depression: results from the STEP-BD randomised controlled trial of psychosocial treatment

BACKGROUND: Little is known about predictors of recovery from bipolar depression. AIMS: We investigated affective instability (a pattern of frequent and large mood shifts over time) as a predictor of recovery from episodes of bipolar depression and as a moderator of response to psychosocial treatment for acute depression. METHOD: A total of 252 out-patients with DSM-IV bipolar I or II disorder and who were depressed enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) and were randomised to one of three types of intensive psychotherapy for depression (n = 141) or a brief psychoeducational intervention (n = 111). All analyses were by intention-to-treat. RESULTS: Degree of instability of symptoms of depression and mania predicted a lower likelihood of recovery and longer time until recovery, independent of the concurrent effects of symptom severity. Affective instability did not moderate the effects of psychosocial treatment on recovery from depression. CONCLUSIONS: Affective instability may be a clinically relevant characteristic that influences the course of bipolar depression.

Learning entry profiles of children with autism from multivariate treatment information using restricted boltzmann machines

Entry profiles can be generated before children with Autism Spectrum Disorders (ASD) begin to traverse an intervention program. They can help evaluate the progress of each child on the dedicated syllabus in addition to enabling narrowing down the best intervention course over time. However, the traits of ASD are expressed in different ways in every individual affected. The resulting spectrum nature of the disorder makes it challenging to discover profiles of children with ASD. Using data from 491 children, traversing the syllabus of a comprehensive intervention program on iPad called TOBY Playpad, we learn the entry profiles of the children based on their age, sex and performance on their first skills of the syllabus. Mixed-variate restricted Boltzmann machines allow us to integrate the heterogeneous data into one model making it a suitable technique. The data based discovery of entry profiles may assist in developing systems that can automatically suggest best suitable paths through the syllabus by clustering the children based on the characteristics they present at the beginning of the program. This may open the pathway for personalised intervention.